Rural Health in the Interim Report of the Standing Senate Committee on Social Affairs, Science and Technology

In December 1999, the Standing Senate Committee on Social Affairs, Science and Technology, chaired by the Honourable Michael J. L. Kirby, began examining the state of the health care system in Canada.

Titled Rural Health, Chapter 10 of Volume II of The Health of Canadians - The Federal Role is devoted to discussing health issues that are of concern to those living in rural and remote areas of Canada.

The following is from The Health of Canadians - The Federal Role Volume Two: Current Trends and Future Challenges. It contains Chapter 10 in its entirety.

CHAPTER TEN: RURAL HEALTH

Rural Canada occupies 9.5 million square kilometres, or about 95 percent of Canada's territory. Approximately nine million Canadians, or about 30 percent of the total population, live in rural and remote areas of the country. Rural and remote areas in Canada embrace varied terrain and economic activities spanning resource, manufacturing and service industries. Observations about rural Canada suggest some defining characteristics:

Rural Canada includes rural and remote communities as well as small towns outside major urban centres.

Rural populations that are more distanced from urban centres continue to decline, particularly as young people leave for educational and employment opportunities and as seniors leave to seek greater access to long-term care.

Rural populations in closer proximity to cities or in recreational areas are increasing.

Across Canada, more than half of the Aboriginal peoples (whether on reserves or in Inuit or Métis communities) live in rural areas.

Ontario and British Columbia have the lowest percentage of rural residents while the territories and Atlantic provinces have the highest. Almost half of the population in Atlantic Canada live in rural areas.

Seniors, children and youth under the age of 20 are over-represented in rural regions of Canada. More precisely, the 1996 Census shows that, compared with the national average, rural Canada has a higher percentage of children between the ages of 5 and 19, a lower percentage of males between 20 and 39 and females between 20 and 49, and a higher percentage of males over 55 and females between 60 and 69.

Rural people living in the Prairie provinces have a lower unemployment rate than do people living in Atlantic Canada.

10.1 Health Status Indicators

A recent report, entitled Rural, Remote and Northern Health Research: The Quest for Equitable Health Status for All Canadians, points out that there is not a great deal of information available on the health of rural Canadians, although data on life expectancy, death rates and infant mortality rates give some broad indicators of health. Overall, compared to urban areas, life expectancy in rural regions is shorter while death rates and infant mortality rates are higher. In 1996, life expectancy for rural females was 80.82 years as opposed to 81.31 years for urban females. The comparable figures for rural and urban males were 74.67 years and 75.67 years, respectively.

Overall, the health status of rural and remote residents is lower than that of their urban counterparts. Dr. Peter Hutten-Czapski, President of the Society of Rural Physicians of Canada, noted:

Health status decreases as one travels to more rural and remote regions. As an example, heart disease is common in northern Ontario. Certain types of cancer are found among miners and farmers. There are substantially higher rates of diabetes, respiratory and infectious diseases, as well as violence-related deaths, in some aboriginal communities. Combined, there is an increase in mortality in rural regions as evidenced by life span.

The lower life expectancies are not associated with just a few specific causes; rather, the mortality rates in these regions are higher for most causes of death. Consistent with other measures of the health of the population, there is an association with socio-economic factors: life expectancy decreases as the rate of unemployment increases and the level of education decreases.

The health and health care needs of rural Canadians are different from those of Canadians living in urban areas. As Health Canada's Office of Rural Health pointed out:

Rural realities and health needs differ from those of urban areas. These needs may be particular to the environment (e.g., the need for education on tractor roll-over prevention), changing demographics (e.g., an increase in the seniors' population in some rural areas), a common health need present in a rural environment (e.g., the health status of First Nations' communities), or the need for health concerns to be expressed in a 'rurally sensitive' way (e.g., obstetrical services that do not generate an excessive 'travel burden' on rural women).

This statement highlights some of the particular populations in rural Canada that may have special needs based on factors such as age, gender, ethnicity, and occupation. For example, various studies have shown that:

Seniors in Canada are over-represented in rural regions, as are children and youth under the age of 20. There are particular issues for seniors needing assisted home care or long-term care and for children and youth with special medical needs or who are in abusive situations.

Farmers, fishers, foresters, and miners can face serious health hazards in their jobs. In addition to accidents related to the increasingly complex machinery used in these occupations, there are hazardous exposures to chemicals, noise, long working hours, temperature extremes, infectious diseases, and stress.

While Aboriginal peoples face an array of health problems related to their socio-economic status, they also experience some of the cultural insensitivity experienced by new immigrants such as lack of services in their own language, health care personnel who are unaware of cultural practices, and problems associated with services designed for a mainstream population.

10.2 Access to Health Services in Remote and Rural Areas

The accessibility criterion of the Canada Health Act requires that reasonable access to insured health services be provided to all Canadians on uniform terms and conditions and without financial or other barriers. Dr. John Wootton, former Executive Director of the Office of Rural Health (now Special Advisor on Rural Health, Population and Public Health Branch, Health Canada) raised the problem of accessibility for rural residents, when he stated: "If there is two-tiered medicine in Canada, it's not rich and poor, it's urban versus rural."

Canadians living in rural and remote areas are limited to a smaller range of health care providers when seeking care than are their urban counterparts. Rural hospital closures and centralization of health services have had an impact on rural residents. Rural physicians explained that, when the insured health services are not available from local providers in local health care facilities, rural residents must travel long distances and incur additional costs for transportation and other needs such as hotels. This can also negatively affect their health:

We must understand that if rural people are forced to travel for care, some will not travel. If they do not travel, they cannot achieve the health outcomes of people who are able or willing to travel. Some will travel, but the delay caused by the travelling or the need to travel will be costly to them. Others will be subject to the hazards of transport or inclement weather. Collectively forcing people to travel long distances for health care, even to a centre of the highest standards, will adversely affect health outcomes.

This is a particular concern for women's health. Studies show that women do poorly if they must travel long distance to give birth. In Saskatchewan, it should be noted, the 1993 closure of 53 rural hospitals was followed by an increase in its perinatal mortality rate. We cannot say that these things are causal, but it is certainly concerning.

The recruitment and retention of health care personnel including physicians, specialists, nurses, technicians, social workers, physiologists and nutritionists, in remote and rural areas of Canada have been ongoing concerns. Access to physician services is a particular problem. For example, Dr. Hutten-Czapski stated:

Doctors are concentrated where the most healthy people in the country live, and the sickest populations have the least access to health care, so the gap between urban and rural grows.

Physician shortages in rural and remote communities have been persistent and are expected to continue. According to the Canadian Medical Association:

While approximately 30% of Canadians live in rural or remote areas, only 10% of Canadian physicians practise outside Census Metropolitan Areas or Census Agglomerations;

Of the approximately 5,700 rural physicians, 87% are family physicians;

While the majority of rural physicians (72%) graduate from Canadian medical schools, the number of Canadian graduates varies from region to region. In Newfoundland, one-third of the rural physicians are Canadian graduates; in Saskatchewan, one-fifth of rural doctors have graduated from Canadian medical schools. In Quebec, 95% of rural physicians have been trained in Canada.

In the early 1990s, the federal and provincial/territorial Ministers of Health considered strategies for physician resource management and by the end of the decade were examining options for both physicians and nurses through the Federal/Provincial/Territorial Advisory Committee on Health Human Resources. A discussion paper prepared for this Committee in 1999, entitled Improving Access to Needed Medical Services in Rural and Remote Canadian Communities: Recruitment and Retention Revisited (Barer and Stoddart, 1999), attributed the lack of access to physicians services in remote and rural areas compared to urban settings to "a fundamental mismatch between the needs of rural and remote communities ... and the needs and choices of (and influences on) those who become physicians." Barer and Stoddart also pointed out:

There are many communities across the country that are simply too small to support a general practitioner, or that are large enough to support one but too small to support two or three, let alone the full range of specialists found in large urban centres. For their part, most Canadians who are accepted into the medical schools across the country have grown up in urban settings; the bulk of their medical training occurs in urban settings; that training takes place largely in tertiary hospitals which are only found in urban settings; much of the training is provided by physician-educators who work in urban settings; there are (given in per capita terms) more practice opportunities in urban settings; access to specialist colleagues and other complementary treatment and diagnostic resources are more plentiful in urban settings; hours of work are more likely to be 'regular' in urban settings and, in particular, call schedules are less onerous; and there are many more social, educational, recreational, employment and cultural opportunities for physicians and their families in urban settings.

Experts suggest that, while policy approaches to dealing with physician shortages in rural and remote areas have been economic or financial, most of the determinants of practice location involve a complex mix of factors involving far more than financial considerations. Personal background, professional education and practice factors, personal considerations (e.g., children's education, recreation, spousal job opportunities) and community size and are also important influences in practice locations. Financial considerations, however, are not as important as personal factors. The physicians who moved for professional reasons also indicated that the presence of certain factors such as additional colleagues, locum tenens (physicians who temporarily carry on the practice for an absent colleague), opportunities for group practice, specialist services and alternative compensation would have influenced them to remain in rural practice.

Unfortunately, there is very little data on registered nurses or other health care providers in similar settings.

A variety of measures have been proposed to help alleviate the shortage of physicians in under-serviced areas. For example, these include:

Reserving undergraduate medical school places for qualified applicants willing to commit to rural area practice;

Enhancing rural area exposure in both undergraduate and post-MD training;

Developing new residency training programs designed explicitly to prepare specialists to serve as rural regional consultants; and

Introducing or increasing financial incentives to encourage choices of specialties in short rural supply.

Provincial and territorial governments have used a number of incentive programs to attract physicians to practice in rural and remote areas. Most of these are financial in nature, but some focus on working conditions, some seek to direct where physicians can establish practices, others recruit foreign medical graduates and others focus on attracting rural residents to attend medical school and providing rural exposure in the course of medical training. Research demonstrates that a greater proportion of trainees from rural settings will return to rural areas because they are already comfortable with the rural culture. As governments acknowledge that it may be easier to retain physicians in rural and remote areas if they have grown up there, programs to attract rural residents to become doctors are becoming more common. One such program will be the creation of a rural medical school in northern Ontario - the "Thunder-Barrie Medical School". Rural physicians challenged the federal government to commit half of the funding for the establishment of rural medical schools in Canada.

Barer, Wood and Schneider (1999) also pointed out that while all provinces and territories face similar issues and problems in relation to the distribution of health services and personnel, there has not been a great deal of cooperation among them in attempting to solve these problems.

William Tholl, Secretary General and CEO of the Canadian Medical Association (CMA), attributes this lack of success to the fact that these financial programs have little to do with the major factors involved in a physician's decision to locate and stay in a rural or remote area - those that are non-financial in nature. Moreover, the lack of cooperation among the provinces suggests that the federal government could play a useful role in fostering inter-provincial collaboration.

It is important to note that Canada is not alone in experiencing problems in providing health services to rural and remote locations. Significant variations in the geographic supply of health services occur in virtually every industrialized country. The United States, Australia and New Zealand, for example, are experiencing health care personnel distribution problems similar to those found in Canada. Like Canada, these countries have adopted a number of policy approaches to deal with these problems.

10.3 Telehealth

Many experts see telehealth as an important vehicle for delivering health services to rural and remote areas. Supporters of telehealth believe that it holds significant promise in this regard. The Office of Health and the Information Highway at Health Canada is promoting telehealth as a way to offer fairer distribution of health resources and to connect patients and health care providers separated by geographic distance. The Society of Rural Physicians of Canada sees both potential and risks in telehealth. The potential lies in its ability to supplement the skills and abilities of existing rural health care workers to deal with problems that would otherwise require patients to travel out of the community to access needed care. The risks, on the other hand, lie in its potential to divert resources away from the local community with the result that needed care can be accessed only from outside sources.

10.4 Rural Health Research

Witnesses confirmed that many gaps exist in information on the health status of individuals and communities in rural Canada. Similarly, there is not a substantial body of research on rural health issues. In the view of witnesses, rural health issues tend to be eclipsed by those in urban areas. Policy solutions often are based on experiences in urban areas and rely on urban data and research. A position paper prepared for the Canadian Health Services Research Foundation and the Social Science and Humanities Research Council pointed out:

Because the health problems confronting rural Canada are serious, complex, interrelated and evolving, research should have a critical role to play in examining the nature of these problems, monitor their progress or deterioration, identifying their causes, finding solutions and evaluating the effectiveness of various interventions. However, to date, rural health research has not received substantial or sustained support from major health research granting agencies in Canada. Generally speaking, within the health research community, rural health issues are either overlooked or dealt within a "generic" manner. In "generic" studies, even when rural is mentioned, it is commonly used as a convenient comparison category to illustrate urban-rural differences. Rural is rarely the focus of attention, yet findings and recommendations from urban-based research are often considered universally applicable or are extrapolated to rural settings.

One of the weaknesses identified in rural health research is lack of coordination and planning. A 1999 Rural Health Research Summit was held to develop a "Blueprint" for future action in rural health research. Other initiatives such as the development of the Canadian Institutes of Health Research (CIHR), increases in health research budgets and the appointment of a special advisor on rural health to CIHR's President have been important developments in rural health research. In addition, a Rural Health Research Consortium was formed in 1999 to build capacity in research endeavours related to health in rural and remote areas.

10.5 The Federal Role

The federal government has responded to the concerns of rural Canadians in a number of ways. For example, the Office of Rural Health was established in September 1998 to ensure that the views and concerns of rural Canadians are better reflected in national health policy and health care system renewal strategies. In February 1999, the federal government announced funding of $50 million over three years (from 1999-00 to 2001-02) to support pilot projects under the "Innovations in Rural and Community Health Initiative."

In June 2000, the federal government announced a National Strategy on Rural Health that it sees as an important milestone on the road to ensuring that all Canadians have reliable access to quality health care. Then, in July 2001, the federal government announced the establishment of a Ministerial Advisory Committee on Rural Health to provide advice to the federal Minister of Health on how the federal government can improve the health of rural communities and individuals.

10.6 Committee Commentary

The Canadian health care system faces many challenges, some of the greatest of which are providing for the health care needs of those who live in rural and remote areas of the country. We know that, generally, rural Canadians have: higher death rates; higher infant mortality rates; and shorter life expectancies than do urban Canadians. We also know that certain types of diseases and conditions are more prevalent in rural areas and among occupations associated with a rural environment. But witnesses pointed out that little is known about the overall health status of rural Canadians. Dr. Judith Kulig, Consortium for Rural Health Research, characterized the adequacy of information on the health status of rural residents as very poor. She attributed this to the limited number of individuals pursuing rural health topics and the limited number of dollars to support research in this field.

Providing equal access to health care is a challenge in rural and remote areas of Canada. The Committee was told that systemic trends such as inadequate numbers of rural doctors and increasing centralization of medical services have the effect of impeding access. The current medical education system is not geared to producing sufficient numbers of doctors who are interested in committing to rural practices; as well, provincial financial incentive programs to attract and retain rural physicians have not had high success rates. Telehealth applications can help solve some of these problems, but they constitute only one part of the solution.

Witnesses emphasized the importance of federal, provincial, and territorial cooperation in developing national strategies to deal with rural health issues whether in the areas of planning, research, health human resources or reducing structural barriers to national rural health policy advancement. They argued for a federal presence in areas such as funding, immigration, planning, evaluation, information-sharing and co-ordination, technology, facilitating consensus, promoting innovative solutions to rural health issues, and an expansion of the mandate of the Health Canada's Office of Rural Health.

The Committee hopes that the recently established Ministerial Advisory Committee on Rural Health will lead to concrete policies and programs that will effectively contribute to enhancing the health of rural Canadians.